臺灣博碩士論文加值系統

過去數十年，高血壓治療的成效雖然大幅提昇，但高血壓疾病控制的成效卻十分有限。病人對治療處置不遵從為影響疾病控制成效的重要因素之一。雖然，探討不遵從的研究很多，但較少研究探討影響病人行為的動機。依據自我調整理論的假設，疾病認同、病因解釋和疾病表徵是影響病人治療遵從行為的重要變項。然而，高血壓被認為是沒有症狀的隱形殺手，高血壓病人如何接受疾病進而遵從治療，很少研究探討。基於此研究旨趣，本研究以自我調整理論假設為架構，以結構方程模式分析技巧，檢視可預測高血壓病人治療遵從的因果行為模式，特別是疾病認同的角色。

本研究採橫斷式問卷調查法，以中部某縣市三家教學醫院心臟內科門診就診的高血壓病人為對象，依取樣和排除條件立意取樣355位病，以結構式問卷：疾病知覺量表（含疾病認同、病因解釋和疾病表徵）、治療遵從行為量表（含藥物治療和自我照顧）收集資料。資料分析使用SPSS 11.0 PC+軟體進行描述性和推論性統計之分析，以LISREL 8.54版檢視量表的測量模式和理論資料模式關係的適配度。研究結果發現：(1)在疾病知覺和遵從行為的相關分析上，相關係數最強的分別為治療控制與和藥物治療遵從總分（r=0.23），和個人控制與自我照顧遵從總分（r=0.33）；而且，病因解釋越多，藥物治療和自我照顧遵從行為越低；(2)在分別比較診斷前後，是否有高血壓症狀的組別，與治療遵從行為的關係時發現，診斷前沒有高血壓症狀者，在運動和自我照顧總分上，顯著高於不確定是否有症狀者。診斷後沒有和有高血壓症狀者，分別在藥物自我調整得分和自我照顧總分得分上，顯著高於不確定診斷後是否有症狀者。而且，診斷後沒有症狀者，在不健康飲食和運動得分上，亦顯著高於不確定診斷後是否有高血壓症狀者；(3)驗證性因素分析結果顯示，疾病認同、病因解釋和疾病表徵，和遵從行為量表（含藥物和自我照顧）皆有良好的因素建構效度、收歛效度、區辨效度、組成信度和內在一致性；(4)結構方程模式結果顯示，資料與理論模式的適配度佳。在控制個案收縮壓、年齡、降壓藥顆數和合併症等變項的影響後發現，疾病認同可經由病因解釋（t=4.05，γ=0.38）和控制（t=-2.28，γ=-0.24），分別影響高血壓病人藥物治療遵從行為和自我照顧遵從行為；控制對藥物治療遵從和自我照顧遵從行為的直接效應分別為β=0.35（t=3.66）和β=0.42（t=2.17）。病因解釋對藥物治療遵從行為影響的直接效應為β=-0.17（t=-2.31）。雖然，疾病認同和病因解釋對負向表徵有直接效應，但負向表徵對治療遵從行為沒有影響。最後模式的路徑效應共可解釋藥物治療遵從行為22.2%的變異量，和44.9%自我照顧遵從行為的變異量。上述結果顯示高血壓病人的俗民見解在其治療遵從行為中的重要性，研究結果也支持以自我調整理論做為探討高血壓病人治療遵從行為研究架構的適用性。

依據本研究結果建議，要提升高血壓病人對治療遵從行為時，應增加病人對疾病的控制能力和澄清不適當的病因解釋，而非單純強調疾病對個人健康負面的影響。再者，高血壓病人對疾病有自己的看法，特別是症狀經驗，即便此經驗可能是主觀的，仍會間接影響病人治療遵從行為。過度強調高血壓的無症狀性，可能加重病人疾病知覺的衝突，徒增持續接受治療的障礙，因為症狀經驗越多，病人對病因的解釋越多，對疾病控制能力越低，藥物治療和自我照顧遵從行為越低。對於有症狀經驗的高血壓病人，特別是收縮壓比較高，較年輕的病人，護理人員需了解病人的經驗感受和對疾病病因解釋的看法，適時予以衛教澄清，以減少接受治療的阻力，提升治療遵從度。

Although the therapeutic effectiveness of hypertension has been significantly advanced in the past decades, the control rate for hypertension is still limited. Non-adherence to therapeutic regimens is considered to be responsible for the low control rate. Although many studies have been conducted to explore the issues of non-adherence, few are focused on patients’ motives. For the study interest, the Self Regulation Model (SRM) is selected as the framework to examine the theoretical assumption of causal model for adherence to therapeutic regimens of patients with hypertension in Taiwan. According to the assumption of the SRM, identity and cause are significant motives for patients seeking medical helps. But, very few studies include illness identity in the adherence study for hypertension is asymptomatic. The specific aim of the study is to explore simultaneously the roles of identity, causal attribution and illness representations on patient adherence behavior using the technique of structural equation modeling.

The study is descriptive with a questionnaire survey design. A purposive sampling will be used to draw out the sample from 3 teaching hospitals in central Taiwan according to the selection and exclusion criteria. A total of 355 valid cases were included in the study. Structured questionnaires such as Illness Perception Questionnaire-Revised (including identity, cause and illness representations) and the Adherence Inventory including the Medication Adherence Inventory (MAI) and the Inventory of Adherence to Self Management (IASM) were used for data collection. Data were analyzed by descriptive statistics as well as inferential statistics using the software of SPSS 11.0 PC+. The software of LISREL version 8.54 was used to analyze the measurement model and structural equations model of adherence to therapeutic regimen of patients with hypertension.

The results of the study found: (1) the strongest correlations were found between treatment control and the total score of MAI, personal control and the total score of IASM. The higher scores of the causes were associated with the lower adherent rates on both the MAI and IASM; (2) The results of ANOVA showed that those who were unsure if they had experienced symptoms after a hypertension diagnosis were more likely to self-regulate (increase or decrease) prescribed medications and less adherent to self management than those without or with symptoms. Those who were no symptoms before or after diagnosis were more likely to adhere to self management activities than those who were uncertain; (3) the findings of confirmatory factor analysis provided evidences supporting both the Chinese versions of Illness Perception Questionnaire – Revised, and Adherence Inventories to be reliable and valid instruments in assessing patients’ beliefs about illness and adherence behavior; (4) the results of structural equation model showed that after controlling the effects of systolic blood pressure, age, total number of the antihypertensive, and comorbidity, identity may influence both patients’ adherence to medication and self management indirectly through control and cause. Negative illness representations showed no effect on both adherence to medication and self management recommendations. Together, direct and indirect effects of control and cause explained 22.2% of variance in adherence to medication; while the explained variance of adherence to self management recommendations were 44.9%.

The findings imply that improvement of sense of controllability can contribute to enhance patients’ adherence to therapeutic regimens, but not negative illness representations. Patients have their own views of disease, especially for those who experienced symptoms related to hypertension. Even though symptom is subjective, it indirectly influences patients’ adherence to therapeutic regimens. The more symptoms the patient report, the more attributions of the illness, the poor sense of controllability of the illness, the lower adherence rate to therapeutic regimens. For patients with high blood pressure related symptoms, the health professionals need to assess individual beliefs about the symptom and illness attribution, clarify misconceptions, so that the barriers of adherence may be reduced, and the adherence rate may be improved. In sum, the findings support the utility of SRM as a theoretical framework in understanding patient behavior of adherence to therapeutic regimens.

標題………………………………………………………………… i
考試委員審定書…………………………………………………… ii
博士論文授權書…………………………………………………… iii
致謝………………………………………………………………… iv
目錄………………………………………………………………… v
中文摘要…………………………………………………………… x
英文摘要…………………………………………………………… xii

第一章 緒論
第一節 研究之重要性………………………………………… 1
第二節 研究動機……………………………………………… 2
第三節 研究目的……………………………………………… 6
第四節 研究問題……………………………………………… 6

第二章 文獻查證
第一節 自我調整模式………………………………………… 7
第二節 自我調整模式相關研究……………………………… 10
一、 疾病知覺變項間的關係……………………………… 11
(一)、一般性研究………………………………………… 11
(二)、高血壓病人的研究………………………………… 12
二、 疾病知覺與遵從行為…………………………………… 13
(一)、一般性研究………………………………………… 13
(二)、高血壓病人的研究………………………………… 14

第三節 高血壓病人的疾病認同……………………………… 17
一、疾病認同的定義………………………………………… 17
二、高血壓病人的疾病認同………………………………… 17
(一)、高血壓相關症狀…………………………………… 18
(二)、高血壓病人的標示效應…………………………… 20
(三)、症狀知覺…………………………………………… 21
第四節 病因解釋……………………………………………… 22
一、 病因解釋的意涵和分類……………………………… 22
二、 病因解釋相關研究…………………………………… 24
第五節 治療遵從……………………………………………… 27
一、 遵從的定義…………………………………………… 27
二、 治療遵從行為的類型與測量………………………… 32
三、 影響遵從行為的因素………………………………… 34
第六節 文獻總結……………………………………………… 36
第七節 理論架構和研究假設………………………………… 38
第八節 名詞定義……………………………………………… 41

第三章 研究方法與材料
第一節 研究方法……………………………………………… 46
一、研究對象……………………………………………… 46
二、研究工具……………………………………………… 47
三、研究工具信效度……………………………………… 49
第二節 資料收集步驟………………………………………… 51
第三節 統計方法……………………………………………… 52
一、描述性和推論性分析…………………………………… 52
二、結構方程模式分析……………………………………… 52
第四章 結果
第一節 個人基本資料………………………………………… 57
第二節 疾病知覺、個人變項與遵從行為關係……………… 61
第三節 類別變項與遵從行為關係…………………………… 62
第四節 測量模式……………………………………………… 65
一、疾病知覺………………………………………………… 65
(一)、題目分析…………………………………………… 65
(二)、測量模式和因素信效度估計……………………… 68
二、治療遵從行為…………………………………………… 76
(一)、題目分析…………………………………………… 76
(二)、測量模式和因素信效度估計……………………… 79
第五節 結構模式分析………………………………………… 86
一、因素結構………………………………………………… 86
二、因素路徑之效應………………………………………… 91

第五章 討論
第一節 樣本基本資料特性…………………………………… 93
第二節 疾病知覺和治療遵從行為…………………………… 93
第三節 量表驗證性因素分析………………………………… 97
一、疾病表徵………………………………………………… 97
二、病因解釋………………………………………………… 99
三、疾病認同…………………………………………………100
四、藥物治療遵從行為………………………………………101
五、自我照顧遵從行為………………………………………103
第四節 高血壓病人治療遵從行為因果模式…………………104
一、結構模式…………………………………………………104
二、病認同的角色……………………………………………105
三、控制的角色………………………………………………106
四、病因解釋的角色…………………………………………106
五、其它路徑關係……………………………………………107

第六章 結論與展望
第一節 結論……………………………………………………109
第二節 限制……………………………………………………110
第三節 貢獻和建議……………………………………………110
參考文獻
中文文獻………………………………………………………… 114
英文文獻………………………………………………………… 115

圖表
圖一 自我調整模式理論架構………………………………… 8
圖二 高血壓病人治療遵從行為理論架構…………………… 39
圖三 疾病表徵因素結構圖…………………………………… 72
圖四 高血壓病人治療遵從行為修正後之結構模式………… 89
表一 不同醫療體系病因解釋和因應行為特性……………… 26
表二 研究假設與相關文獻…………………………………… 40
表三 本研究相關名詞定義一覽表…………………………… 45
表四 模式適配度指標………………………………………… 56
表五 個人基本資料…………………………………………… 58
表六 研究變項描述性統計結果……………………………… 60
表七 疾病知覺、個人變項與遵從行為相關積差分析……… 63
表八 疾病認同類別變項與治療遵從行為ANOVA分析結果… 64
表九　疾病表徵個別項目測量參數估計表…………………… 66
表十　病因解釋個別項目測量參數估計表…………………… 69
表十一　疾病認同個別項目測量誤之參數估計表…………… 70
表十二　二階驗證性因素之模式配適度指標………………… 74
表十三 疾病知覺量表各因素描述性統計和信效度分析表… 75
表十四 各潛在因素之相關及抽取變異量平方根…………… 77
表十五　藥物治療遵從行為個別項目測量參數估計表……… 78
表十六 自我照顧遵從行為個別項目測量誤參數估計表…… 80
表十七 遵從行為量表各因素描述性統計和信效度分析表… 84
表十八 各潛在因素之相關及抽取變異量平方根關係……… 85
表十九　不同模式配適度指標之比較………………………… 87
表二十　控制變項與其它變項的路徑關係…………………… 90
表二十一 潛在變項路徑效果分析表………………………… 92

附錄
附件一 高血壓病人服藥遵從行為量表使用同意書………… 133
附件二 病知覺量表修訂版使用同意書……………………… 135
附件三 專家效度名單………………………………………… 137
附件四 問卷內容……………………………………………… 138
附件五 人體試驗委員會同意書……………………………… 145
附件六 受試者同意書………………………………………… 146

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